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Module 6: Worst Practices in Community Eye Health

In spite of good intentions, community eye health work that does not follow public health best practices can be wasteful, unethical, and harmful. Worst practices are serious public health concerns that create new and oftentimes more substantial barriers to patient care, thereby reinforcing and furthering health disparities. Any organization that attempts to address problems in community eye health means well. However, good intentions do not necessarily have bearing on result. Oftentimes, even well-meaning and well-known organizations can slip into bad habits when it comes to how they attempt to address community needs.  These “worst practices” do not come from malevolence, but rather are the result of being uninformed about the evidence-based approaches that such organizations should be taking to help improve eye health in their communities.  One of the worst practices is when non-medical professionals go beyond the scope of their expertise by making recommendations to community members that they are not qualified to make.  While this may be done with the best intentions, there are serious consequences for the members of the community that volunteers are attempting to serve.

Worst Practice: Community Glaucoma Screening

There are some organizations that allow and encourage their non-medically-trained volunteers to conduct glaucoma screenings by providing a test for intraocular pressure.  However, “screening for glaucoma, usually by measuring intraocular pressure, has been [shown through] repeated analysis [to have] poor sensitivity and specificity,”(1) according to a study conducted by Alfred Sommer in 2007.  Additionally, in some patients with glaucoma, “raised pressure inside the eye may not be present, and many [patients] with raised pressure do not have glaucoma,”(2) according to a meta-analysis performed by Hatt and colleagues.  Therefore, community glaucoma screenings through intraocular pressure are neither valid nor effective. 

Providing intraocular pressure screenings in community settings is problematic because the results are ambiguous, and comprehensive examination and diagnosis by an eye care professional is necessary.  Intraocular pressure (IOP) glaucoma screenings can cause significant harm by informing a community member that their pressure is normal when in reality the patient may have, or be at risk for, glaucoma. Glaucoma screening have a serious and real risk of developing new patient barriers to care. Community members are usually given the false impression that they do not need to seek out a doctor and that whatever vision loss he or she is experiencing is not due to glaucoma.  Non-doctor volunteers who truly wish to serve their communities will steer clear of glaucoma screening because of this potentially egregious harm that it can do to a patient’s ability to seek treatment for glaucoma.

Worst Practice: Giving The Illusion of Comprehensive Care

When a resident or physician sees patients outside their standard clinical environment they cannot be accused of practicing beyond their skill set. Even the best-trained physicians, however, cannot perform a complete medical exam without the proper equipment. When a doctor sees a patient, no matter how cursory the examination, the patient will think they have received a “doctor exam.” This is especially true when the patient is not accustomed to regular doctor visits and doesn’t know the extent of a complete exam. No matter how firmly volunteers, students, or practitioners insist that the patient must obtain a complete doctor’s exam, the patient is unlikely to seek care if they believe they have already been examined. In this way, medical professionals who see patients outside a clinical setting are preventing patients from obtaining health care. Ultimately, the goal of community-based health organizations is not to provide comprehensive medical care, but rather to connect underserved patients with resources that reduce barriers and encourage them to seek continuous, quality health care.(3) Such comprehensive care can only be provided by doctors in a clinic setting, where all equipment is available. 

Worst Practice: Amblyopia Screening and Diagnosis

The U.S. Preventive Services Task Force has published a “B” level recommendation for screening for visual impairment in children under the age of 5.  Early detection is very important in treating amblyopia, which can lead to a loss of sight in one eye and is present in 1-4% of preschoolers.  The USPSTF found one study showing that “intense screening by eye professionals (compared with usual screening) decreases the prevalence of amblyopia.”(4)  Insofar as ‘usual screening’ is concerned, a meta-analysis performed by Powell and colleagues found that “there is currently not enough evidence to determine whether or not screening programmes reduce the proportion of older children and adults with amblyopia.”(5)  The two of these items of evidence, when taken in conjunction, suggest a similar conclusion to that which we can draw from the glaucoma case in example 1: non-medically-trained volunteers should not be screening for specific conditions.  While it is appropriate (and recommended) that volunteers administer simple visual acuity tests, drawing conclusions on the basis of these tests, or terming them “amblyopia screenings,” is inappropriate and can do harm to patients seeking care in the same way as volunteer glaucoma screenings were shown to do in example 1.  The worst thing a volunteer can do is to tell a patient that he or she is healthy on the basis of no professional training whatsoever.

What Volunteers Can Do

When it comes to visual acuity screening, it is appropriate and highly recommended that volunteers refer patients to services that can provide them with professional eye care.  Volunteers should never attempt to examine or diagnose patients. Volunteers should connect community members with resources so that they can receive an eye exam by an eye care professional in a standard clinic environment.  Most volunteers want to help as much as possible, but it is vitally important that they know that attemptig to step outside their roles may do significant harm.

Footnotes

Evidence-Based Community Eye Health Online Course

• Table of Contents
• Module 1
• Module 2
• Module 3
• Module 4
• Module 5
• Module 6